The special challenge of chronic pain

Nurse practitioners have realized a progressively broader scope of practice over the past two decades. This has resulted in the ability to offer more comprehensive care to our patients, and many states now allow NPs to prescribe controlled medications. As NPs continue to acquire the ability to prescribe scheduled medications, they will have to develop an effective approach to the patient experiencing chronic pain.

A number of NPs have practiced independently or in collaborative roles that encompass some level of acute or chronic pain management. While acute pain is of short duration and involves problems that are likely to resolve, chronic pain may persist for years.

Given concerns regarding prescription-drug abuse, it's little wonder that clinicians are apprehensive when large amounts of pain medication are required. Studies have shown that while practitioners are open to prescribing less potent opioids, many are unwilling to prescribe more potent varieties, particularly when patients require constant pain coverage.

Chronic pain results in a prominent affective element. These patients frequently suffer emotional as well as somatic manifestations of pain. Many chronic pain sufferers are classified as “difficult” patients who appear addicted. This can lead to undertreatment of pain. And undertreatment, in turn, can lead to a situation in which patients demand increasingly larger amounts of pain medication, thus straining the patient-provider relationship.

Most commonly prescribed pain medications are compounds of acetaminophen with hydrocodone, oxycodone, propoxyphene, or codeine and are generally taken every four to six hours. Patients with chronic pain may require two tablets every four to six hours, or 300-400 tablets monthly. Large prescriptions are not always realistic in today's environment. Longer-acting preparations that require once- or twice-daily dosing offer more stable pain control with fewer doses and side effects. Sustained-release oral forms of morphine and oxycodone address this need. Additionally, transdermal fentanyl offers stable pain control with patch application every 72 hours.

Several techniques can minimize the risk of prescription-drug abuse. Ensure that the patient's diagnosis is clearly documented, including tests and consultations. Incomplete records may reflect large amounts of prescribed narcotics without a clearly delineated disease process.

The rationale, nature and parameters of therapy are required to establish a contractbetween the primary-care practitioner, pain-management specialist and the patient. This results in a close delineation of roles and limits to therapy while protecting the provider if the patient fails to meet the stipulations of the contract.

Finally, urine screening can be used to monitor therapy. Extra medications, whether prescription or illicit, are potentially harmful and alter the dynamics of a carefully thought-out regimen.

As clinicians, our professional and ethical underpinnings require that we adequately control pain and suffering in the patients entrusted to our care. Failure to properly treat patients suffering legitimate chronic pain syndromes will likely result in a compounding of prescription pain-medication abuse.

James Whyte, MSN, ND, NP, is a primary- and acute-care nurse practitioner and an assistant professor at Florida State University School of Nursing in Tallahassee.

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